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ORIGINAL ARTICLE
Year : 2012  |  Volume : 26  |  Issue : 3  |  Page : 163-166

Pattern of disease in palpable supraclavicular lymph node: A cytopathological perspective


Department of Pathology, Regional Institute of Medical Sciences, Lamphelpat, Imphal, Manipur, India

Date of Web Publication10-Jun-2013

Correspondence Address:
Rajesh Singh Laishram
Assistant professor, Department of Pathology, Regional Institute of Medical Sciences, Lamphelpat, Imphal, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958 .113238

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  Abstract 

Objectives: To study the pattern of diseashe in palpable supraclavicular lymph node using fine needle aspiration cytology (FNAC) in Regional Institute of Medical Sciences (RIMS) Hospital, Imphal, Manipur. Materials and Methods: A retrospective study was done by critically analyzing the FNAC reports of palpaple supraclavicular lymph node in last 5 years (January 2006-December 2010) at the Department of Pathology, RIMS Hospital, Imphal, Manipur. Review of all the reports were done and diagnosis was made according to standard guidelines and correlated with patient's age, sex, and side of involvement to explore the disease pattern. Results: Out of 255 cases, 48.28% were metastatic tumors, 27.5% were tuberculous lymphadenitis, 15.3% were of non-specific reactive lymphadenitis, 4.3% were non-caseating granulomatous lymphadenitis, 2.7% were of lymphoma and 1.96% was of acute suppurative lymphadenitis. Mean age of presentation of metastatic tumor was 57 years, whereas in case of tuberculous (Tb) lymphadenitis it was 34.5 years. Females were more commonly affected than males with male female ratio of 1:1.4. Left sided involvement was seen in 50%, right sided involvement in 46% and bilateral involvement in 4% of patients. Conclusion: Enlarged supraclavicular lymph node often has some serious underlying pathology both in young adults and old patients. Further, our study highlights the importance of FNAC in the initial evaluation of enlarged supraclavicular lymph nodes.

Keywords: Metastatic tumors, Supraclavicular lymph node, Tuberculous lymphadenitis


How to cite this article:
Laishram RS, Devan R M, Laishram S, Sharma DC. Pattern of disease in palpable supraclavicular lymph node: A cytopathological perspective. J Med Soc 2012;26:163-6

How to cite this URL:
Laishram RS, Devan R M, Laishram S, Sharma DC. Pattern of disease in palpable supraclavicular lymph node: A cytopathological perspective. J Med Soc [serial online] 2012 [cited 2020 Oct 30];26:163-6. Available from: https://www.jmedsoc.org/text.asp?2012/26/3/163/113238


  Introduction Top


Assessment of enlarged supraclavicular lymph node often raises serious caution among pathologists and clinicians, as it can be the first clinical sign of underlying malignancy. [1] Apart from metastasis, a wide range of disease process like reactive, infective, and primary neoplasm can occur in supraclavicular lymph node. Parameters like age, sex, and site of lymph node involvement corroborates well with disease frequency. [2]

Many studies have highlighted the importance of fine needle aspiration cytology (FNAC) in diagnosing enlarged lymph node with high sensitivity and specificity. [3],[4],[5],[6] The present study is undertaken to know the disease pattern in palpable supraclavicular lymph node using FNAC in Regional Institute of Medical Sciences (RIMS) Hospital, Imphal, Manipur.


  Materials and Methods Top


This is a retrospective study carried out in Department of Pathology, RIMS, Imphal, Manipur. All FNAC reports and smears of palpable supraclavicular lymph node in last 5 years (January 2006-December 2010) were retrieved from cytology section. They were reviewed for age, sex, laterality, cytomorphology, and diagnosis. Cases in which, aspirate was inadequate or results equivocal were excluded from the study. Smears were routinely stained with Giemsa and special stains applied wherever needed. Standard guidelines for cytological diagnosis were followed. [7]

Cases with epithelioid granuloma, langhan's giant cells, and caseation necrosis or acid fast bacilli ositivity in Ziehl-Neelsen stain were reported as tubercular lymphadenitis. Epithelioid granuloma without caseation necrosis was reported as non caseating granulomatous lymphadenitis (NCGL). [8] Results were grouped as non specific reactive lymphadenitis (NSRL), acute suppurative lymphadenitis, tuberculosis (Tb), NCGL, lymphoma, and metastatic lymphadenopathy. Their pattern of distribution was assessed according to patient's age, sex, and side of involvement.


  Results Top


Out of 267 cases, 12 cases were excluded, due to inadequate material or equivocal results. In remaining 255 cases, cytodiagnosis was possible. There were 106 males (41.6%) and 149 females (58.4%) with male to female ratio of 1:1.4. Age of presentation ranged from 7 years to 88 years with mean age of presentation being 49.5 years. More patients had left-sided enlargement (127/255: 50%) than right-sided (118/155: 46%), and bilateral presentation (10/255: 4%). Among various diseases involving supraclavicular lymph node, metastatic tumors were commonly seen in our study (123/255; 48.24%) followed by Tb (70/255; 27.5%). There were 39 cases of NSRL (15.3%), 11 cases of NCGL (4.3%), seven cases of lymphoma (2.7%), and five cases of acute suppurative lymphadenitis (1.96%). Out of seven lymphomas, six were non-Hodgkin lymphoma (NHL) and one was HL. Age wise distribution of various diseases is given in [Table 1].
Table 1: Pattern of disease in relation to age in decades

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Most cases of metastatic tumors were on the left side (67/123) whereas Tb tended to occur on right side (40/70). A wide range of metastatic tumors were seen in our study ranging from well differentiated to undifferentiated carcinoma. There were adenocarcinoma (53/123), squamous cell carcinoma (19/123), undifferentiated carcinoma (33/123), small cell carcinoma (9/123), ductal carcinoma of breast (6/123), hepatocellular carcinoma (2/123), and papillary carcinoma of thyroid (1/123). The pattern of distribution of various metastatic tumors in relation to side of involvement is shown in [Table 2]. [Table 3] shows the various primary sites for the metastatic cases where lungs are the most common site followed by nasopharynx [Figure 1] and [Figure 2].
Figure 1: Photomicrograph showing metastatic adenocarcinoma from lung having an acinar pattern (Giemsa, ×400)

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Figure 2: Phtomicrograph of metastatic small cell carcinoma from lung showing nuclear moulding with 'salt & pepper' appearance of chromatin (Giemsa, ×400)

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Table 2: Magnitude of metastatic tumors in relation to side

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Table 3: Different primary sites in the metastatic lesions

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  Discussion Top


FNAC being a simple and rapid diagnostic procedure, it is routinely used as first line of investigation for assessing lymph node enlargement particularly metastatic lymphadenopathy. [9] In our study, supraclavicular lymph nodes were commonly involved by metastatic tumors (123/255:48.24%) which is comparable to studies done in India and other countries. [10],[11],[12] This can be attributed to vast lymphatic drainage by supraclavicular lymph node from thoracic, abdominal, and pelvic organs which serve as a seat of malignancy in old age. They were seen from 30 years to 88 years with mean age of presentation being 57 years. The incidence of malignancy rose steadily with increasing age especially after 60 years of age. There is a pressing need for FNAC of enlarged supraclavicular lymph nodes in the elderly which can provide an early clue to the diagnosis. [10] Commonest primary sites include the lungs, nasopharynx, stomach, breast etc., These findings corroborate with those of earlier studies. [11],[13] However, we found a higher incidence of nasopharyngeal carcinoma (NPC) unlike other studies. This could be attributed to the higher incidence of NPC in this part of the country. In Manipur, it is the third most common cancers in males and ninth in females as per cancer registry. [14] The commonest clinical presentation of NPC is found to be neck swelling. [15] Adenocarcinoma was the most common metastatic tumor in our study with preponderance to left side. However, squamous cell carcinoma predominated in a study by Mitra et al. [10]

Tb was 2 nd most common disease contributing 27.5% (70/255) which is slightly higher when compared to studies done in other parts of India 10, 11. High prevalence of HIV in Manipur [16] could be the reason for opportunistic infections like Tb to occur in more number. The age of presentation of Tb ranged from 10 years to 75 years (mean age = 34.5 years). Most cases were seen in the 3 rd and the 4 th decade of life.

There were 39 cases of NSRL, making 15.3% of supraclavicular lymph node enlargement and seven cases of lymphoma (2.7%). However, Mitra et al. [10] reported in 5.1% of his series. All cases of lymphomas presented with multiple lymph node enlargements. There were six cases of NHL and one case of HL. Among NHLs, four were large cell type and two were small cell type. Majority of cases were seen in 6 th decade and one case of HL was seen in 2 nd decade.

It is discernible from the present study that supraclavicular lymph nodes are frequently enlarged by metastatic tumors followed by Tb. The pattern of various diseases in supraclavicular lymph node in relation with different parameters is well documented. This will facilitate pathological reporting and aid clinicians to make focused investigation and plan appropriate treatment.


  Conclusion Top


Thus enlarged supraclavicular lymph node often has some serious underlying pathology both in young adults and old patients. In such cases, FNAC not only helps to arrive at definite diagnosis but also gives clue to primary site in case of metastatic tumor.

 
  References Top

1.Moore KL. The thorax. In: Clinically Oriented Anatomy. 2 nd ed. Baltimore: Williams and Wilkins; 1985. p. 49-148.  Back to cited text no. 1
    
2.Cervin JR, Silverman JF, Loggie BW, Geisinger KR. Virchow′s node revisited. Analysis with clinicopathologic correlation of 152 fine-needle aspiration biopsies of supraclavicular lymph nodes. Arch Pathol Lab Med 1995;119:727-30.  Back to cited text no. 2
    
3.Hsu C, Leung BS, Lau SK, Sham JS, Choy D, Engzell U. Efficacy of fine-needle aspiration and sampling of lymph nodes in 1,484 Chinese patients. Diagn Cytopathol 1990:6:154-9.  Back to cited text no. 3
    
4.Haque MA, Talukder SI. Evaluation of fine needle aspiration cytology (FNAC) of lymph node in Mymensingh. Mymensingh Med J 2003;12:33-5.  Back to cited text no. 4
    
5.Malakar D, Jajoo IL, Swarup K, Gupta OP, Jain AP, Poflee VW. A clinical evaluation of fine needle aspiration cytology in the diagnosis of lymphadenopathy. Indian J Tuberc 1991;38:17.  Back to cited text no. 5
    
6.Rakshan M, Rakshan A. The diagnostic accuracy of fine needle aspiration cytology in neck lymphoid masses. Iranian J Pathol 2009;4:147-50.  Back to cited text no. 6
    
7.Heerde PV, Miliauskas J, Field A. Lymph nodes. In: Orell SR, Sterrett GF, Whitaker D, editors. Fine Needle Aspiration Cytology. 4 th ed. New Delhi: Elsevier; 2010. p. 83-124.  Back to cited text no. 7
    
8.Ahmed SS, Akhtar S, Akhtar K, Naseem S, Mansoor T. Study of fine needle aspiration cytology in lymphadenopathy with special reference to acid-fast staining in case of tuberculosis. JK Sci 2005;7:1-4.  Back to cited text no. 8
    
9.Ghartimagar D, Ghosh A, Ranabhat S, Shrestha MK, Narasimhan R, Talwar OP. Utility of fine needle aspiration cytology in metastatic lymph nodes. J Pathol Nepal 2011;1:92-5.  Back to cited text no. 9
    
10.Mitra S, Ray S, Mitra PK. Fine needle aspiration cytology of supraclavicular lymph nodes: Our experience over a three-year period. J Cytol 2011;28:108-10.  Back to cited text no. 10
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11.Gupta N, Rajwanshi A, Srinivasan R, Nijhawan R. Pathology of supraclavicular lymphadenopathy in Chandigarh, north India: An audit of 200 cases diagnosed by needle aspiration. Cytopathology 2006;17:94-6.  Back to cited text no. 11
    
12.Adhikari RC, Jha A, Sayami G, Shrestha S, Sharma SK. Fine needle aspiration cytology of palpable supraclavicular lymph nodes. J Pathol Nepal 2011;1:8-12.  Back to cited text no. 12
    
13.Lee J. Usefulness and limitations of fine needle aspiration cytology in adult cervical lymph node enlargement patients: An analysis of 342 cases. Tuberc Respir Dis 2004;56:18-28.  Back to cited text no. 13
    
14.National cancer Registry programme. Annual report of Population based cancer registry, Imphal, Manipur State. Indian Counc Med Res 2009:33-4.  Back to cited text no. 14
    
15.Sharma TD, Singh TT, Laishram RS, Sharma LD, Sunita AK, Imchen LT. Nasopharyngeal carcinoma: A clinico-pathological study in a regional cancer centre of northeastern India. Asian Pac J Cancer Prev 2011;12:1583-7.  Back to cited text no. 15
    
16.Executive summary. Manipur AIDS control society, 2008. Available from: http://manipursacs.nic.in/html/archive. html. [Last updated 2011 Aug 12: Last cited 2011 Oct 25].  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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